Viewpoint: Medicaid-Based Improvements in Depression Can Lead to Broader Health Benefits

Improvements in treating depression could lead to broader benefits in other health outcomes.

A new study of Oregon’s expansion of Medicaid disappointed advocates by failing to find improvements in health measures like high blood pressure and cholesterol within two years— but it did show a 30% reduction in depression rates. While these results are far from ideal, we shouldn’t underestimate the broader and long term impact—in both health and human costs— that simply cutting depression could have.

According to the World Health Organization [PDF], depression is the leading cause of disability worldwide in terms of productive years lost. In the U.S., only back pain takes away more years of healthy function and the most recent analysis available shows that work hours lost to depression cost the economy some $83 billion annually. On average, 7% of Americans are depressed in a given year, contributing in part to nearly 40,000 suicides yearly.

The Oregon Medicaid study itself grew out of a dire economic reality: the state couldn’t afford to expand access to everyone eligible, so it held a lottery. The situation provided the ideal setting for documenting how effective the Medicaid program is in providing needed preventive and treatment services — by comparing the health of the winners and losers during the program’s first two years. The researchers found no significant differences in blood pressure, diabetes control or cholesterol among the beneficiaries and non-beneficiaries, although they discovered increases in treatment and uptake of preventive services.

The winners, however, did show real improvements in mental health, as well as virtual elimination of bankruptcies and other financial catastrophes due to medical expenses — which may or may not have been related to their healthier mental state. There was no difference between the winners and the losers in terms of antidepressant use, however, so it’s likely that the stress relief from having health insurance played a role.

“To my mind, the depression results are phenomenal,” says Harold Pollack, professor of public policy at the University of Chicago, “It’s a combination that can’t be untangled: people have serious financial stress and anxiety, which is lowered. And they are now in care for those issues. The depression results happen so quickly it’s clear that you’re basically relieving at least some chunk of major life stress. Plus they won a lottery and I would not discount that.”

While the lack of improvement in other health measures was discouraging, especially for advocates of universal health care, who have argued that coverage can lead to both improved health and health care savings, the reduction in depression rates could be a harbinger of broader benefits to come.

Depression, for instance, is strongly linked with cardiovascular disease— a major driver of health costs— in ways that are not fully understood. But some of heart disease‘s risk factors, including overeating, could be addressed, in part, by relieving depression. The same early childhood adversities, such as neglect, that can contribute to depression may also biologically increase risk for heart disease and stroke.

Research also shows that depression has a negative impact on other behaviors, such as addictions, that can lead to poor health and carry major costs. One recent study found that adolescents with depression had double the risk of obesity, compared to mentally healthy youth. And around 12% of new cases of alcoholism and 30% of long-term alcohol disorders in adults can be attributed to drinking to relieve negative moods, according to another recent study. The same almost certainly holds true for other drugs, both legal and illegal. The benefits and savings, both to society and the individual, may also appear outside of the health system, in the form of reduced crime and unemployment.

Another, often hidden cost of depression is its effect on parenting. A growing body of work now shows that maternal depression is bad for babies, affecting their intellectual and emotional development at a crucial time when their brains are most vulnerable. At its worst, depression can be linked with child neglect and domestic violence (among both perpetrators and victims), all of which can set up a vicious cycle that echoes through the generations. And that’s not to mention the horrific impact suicide has on families. Again, the savings here might come outside the health system: in reduced child welfare and crime, and in improvements in quality of life and employment.

Of course, none of this even begins to describe the relief from individual suffering that comes from lifting depression. Anyone who has struggled with the disease— as I have— knows that it insidiously eats away at everything we value most. Even if expanding access to healthcare doesn’t demonstrate immediate effects on physical health measures, a two year study can’t begin to show the impact that reducing depression by nearly a third will ultimately have on social costs and real lives. It’s not the stunning success that Oregon’s officials— or proponents of universal health care—were hoping for, but it’s a critical, and valid first step.

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